Part 1 - General
Chapter 8 -
Managing The Workers' Compensation Program
- Purpose. This chapter prescribes policies, procedures and identifies staff responsibilities for managing the Workers' Compensation Program for the Indian Health Service (IHS) under Title 5, United States Code Chapter 81, Federal Employees Compensation Act (FECA). It outlines the provisions of FECA within IHS in the processing of injury compensation reports and claims. It is applicable to reports and claims filed in connection with or by employees under the IHS appointing authority.
- Policy. It is IHS policy that FECA provisions are managed to ensure appropriate compensation for injured employees and cost-effective use of human resources by the agency. Specifically:
- When an employee is partially or totally disabled, it is the policy of the agency to assist the employee in preparing and forwarding necessary claim forms and supporting documents required to apply for all benefits for which eligible under FECA, that include:
- Medical services and, if appropriate, rehabilitative therapy as soon as possible following any work-related injury.
- Referrals, when appropriate, for vocational rehabilitation counseling and training when permanent injury has occurred.
- Workers' compensation during periods of reduced employment or total absence from the worksite as approved under FECA guidelines.
- When an employee is temporarily or partially disabled, it is the policy of the agency to locate a light duty or alternative assignment or to provide reasonable accommodation.
- Coverage. All IHS employees are covered by this chapter, except officers of the Commissioned Corps of the United States Public Health Service. Coverage is provided while employees are on the premises of their work stations for work-related purposes while entering or exiting from their work premises, while on officially authorized travel, while attending authorized meetings or serving on details away from their regular work stations, while engaging in official duties on work-at-home projects, flexiplace, and while serving as Federal petit or grand jurors.
- Area Office - IHS Area offices outside of Headquarters, Rockville, Maryland; includes all 12 Area offices, and Office of Health Program Research and Development.
- Benefits or Compensation - The money paid or payable under the FECA to the employee on account of loss of wages or loss of wage earnings.
- Claim - A statement in writing of an employee's entitlement to benefits under or pursuant to FECA, submitted in a form and manner authorized by the provisions of this Instruction.
- Claimant - An individual whose claim for entitlement to benefits under FECA has been filed in accordance with FECA and the provisions of this Instruction.
- Continuation of Pay (COP) - An employee who files a claim for a period of wage loss caused by a traumatic injury shall be entitled, under certain circumstances, to have his/her-regular pay continued for a period not to exceed 45 days. This cost is paid by the employing office (Headquarters, Area, service unit, etc.), not workers' compensation. It shall be considered regular income and not compensation, and shall be subject to all taxes and other payroll deductions applicable to regular income.
- Disability - Incapability because of employment injury, to earn the wages the employee was receiving at the time of his/her injury.
- Employee - A civil officer or employee in any branch of the Government of the United States, including an officer or employee of an instrumentality wholly owned by the United States.
- Employee Health Specialist - A nurse, physician, or other health care provider who will work with the Occupational Safety and Health Officer (OSH) and Servicing Personnel Office (SPO) as a multidisciplinary management team coordinating all occupational health and safety activities.
- Employee Medical Folder - (EMF) A separate folder/file (SF-66D) that contains all medical records designated for long-term retention in conjunction with employment.
- FECA - Federal Employees Compensation Act, Title 5, United States Code (USC), Chapter 8101.
- Federal Grand and Petit Jurors - The term "juror" means an individual selected pursuant to Chapter 21 of Title 28, USC, and serving as a petit or grand juror, (i.e., summons to attend court, in deliberation, and sequestered by order of a judge).
- Headquarters - IHS offices in Rockville and Perry Point, Maryland, and the Clinical Support Center, Phoenix, Arizona, and Headquarters West, Albuquerque, New Mexico.
- Injury - A wound or condition of the body induced by accident or trauma, and includes a disease or illness proximately caused by the employment for which benefits are provided under FECA. The term injury includes damage to or destruction of medical braces, artificial limbs, and other prosthetic devices that shall be replaced or repaired; except that eyeglasses or hearing aids shall not be replaced, repaired, or otherwise compensated for, unless the damage or destruction is incident to a personal injury requiring medical services.
- Occupational Disease or Illness - A condition produced in the work environment over a period longer than a single workday or shift by such factors as systemic infection; continued or repeated stress or strain; or exposure to hazardous elements such as, but not limited to, toxins, poisons, fumes, noise, particulates, radiation, or other continued or repeated conditions or factors of the work environment.
- OWCP - Office of Workers' Compensation Program, of the Department of Labor.
- Pay Rate for Compensation Purposes - Means the employee's pay, as determined under section 8114, FECA, at the time of injury, or at the time disability begins, or at the time compensable disability recurs if the recurrence begins more than 6 months after the injured employee resumes regular full-time employment.
- Physician - The term "physician" includes physicians (M.D. and D.O.), surgeons, podiatrists, dentists, clinical psychologists, optometrists, and chiropractors, within the scope of their practice as defined by State Law. This includes chiropractors only to the extent that their services are limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist.
- Representative - A person authorized by a claimant in writing to act for the claimant in connection with a claim or proceeding under FECA or this Instruction. Where a claimant is physically or mentally incapable of making such a designation, it may be made by the claimant's family member, union representative, and a HHS official (i.e., a supervisor).
- SPO- Servicing Personnel Office for your official duty station.
- Traumatic injury - A wound or other condition of the body caused by external force, including stress or strain, which is identifiable as to time and place of occurrence and member or function of the body affected.
The Department of Labor (DOL) has nationwide responsibility for FECA. The administration of FECA within the DOL is assigned to the OWCP. The OWCP manages the overall FECA program Governmentwide; authors regulations governing FECA for publication in the Federal Register
; authors guidance to personnelists on FECA administration for publication by the Office of Personnel Management (OPM); approves or disapproves all claims under FECA for compensation and medical costs; and authorizes plans for rehabilitative therapy or vocational rehabilitation programs.
Initial reports of costs are provided by OWCP to the Department of Health and Human Services (HHS) quarterly. Costs are subsequently paid from a revolving fund that covers fiscal years of July 1 - June 30. Billings to agencies for reimbursement are made 2 fiscal years after the costs are incurred by OWCP. The OWCP also provides periodic training programs for agency personnel that explain FECA administration and use of OWCP forms.
- Headquarters. Headquarters is responsible for the overall monitoring and controlling of personnel management aspects of FECA provisions as they relate to employees, supervisors, and managers within the IHS and for establishing plans for full accountability for the management of the injury compensation program within IHS.
Headquarters will have the same responsibilities as the Areas in FECA case management. In addition, once the bill from OWCP is received, Headquarters will break down the costs according to the billing code number given to each Area for their costs.
- Area Office. Each Area Director encourages the SPOs and supervisors to seek second medical opinions from either DOL or an IHS source at the Agency's expense; request investigations of suspected waste, fraud, or abuse; approve separations from HHS rolls of permanently, totally disabled FECA recipients, and monitor the recovery status of former IHS employees receiving compensation.
Each Area Director will also be responsible for ensuring that employees are offered light duty, alternative assignments, or reasonable accommodation as soon as the employee's physician report indicates light duty work.
- Servicing Personnel Office. Each SPO will be responsible for monitoring and controlling all personnel administration aspects of FECA provisions as they relate to employees of the SPO's servicing area including:
- Establishing a FECA case monitoring file for each case forwarded to the SPO separate from the employee's EMF.
- Representing management on all OWCP cases and serving as the focal point for communication with DOL and OWCP.
- Informing supervisors that an initial FECA claim submitted by an employee or prepared by the supervisor must be forwarded to the SPO within 5 workdays following the injury.
- Reviewing the claim for completeness and accuracy before forwarding it to the OWCP district office, and ensuring that the forms have the proper OWCP/Occupational Health and Safety Administration (OSHA) codes, proper agency identifier, and original signatures.
- Assisting supervisors in the controversion of apparently non-meritorious claims.
- Assisting in the development of a light duty assignment program and coordinating, on an ongoing basis, light duty assignments.
- Counseling supervisors to inform all employees receiving FECA benefits that physician's reports certifying continued disability are required:
- Once every 2 weeks during the initial period of a FECA claim.
- Less than once every 2 weeks only when authorized by the OWCP district office.
- The SPO will monitor each currently active FECA benefit case and consult with the supervisor biweekly regarding:
- Light duty or alternative work assignments in the supervisor's area of responsibility.
- Grounds for seeking second medical opinion.
- Grounds for seeking an investigation of possible waste, fraud, or abuse.
- Assuring that claim forms protecting the employee's entitlements are being completed and forwarded to the SPO in a timely manner.
- Counseling permanently injured employees whom OWCP has determined to be unable to perform the critical elements of their regular position and who are eligible for either an annuity under civil service retirement or long-term compensation from OWCP.
- Ensuring that all claimants have a EMF. The EMF will be used to store all records on employee occupational illness/diseases, accidents, injuries, exposures, and other medical or health maintenance matters. All EMFs will be contained in SF-68B, "Employee Medical File." All EMFs will be developed and maintained in accordance with the established system of Records.
- Employee Health Specialists. They are responsible for:
- Providing emergency diagnosis and first treatment of injury or illness.
- Providing definitive treatment, or referral for occupationally-acquired illness or injury.
- Ensuring that all occupational health medical records are maintained as described in the established System of records. Any medical record generated as a result of treatment for occupational illness or injury, as well as medical surveillance information, will be kept in the employee's medical record in a separate section entitled "Employee Health Medical Record." The information in an employee's medical record is kept in strict confidence; however, a copy of his/her record can be obtained by the employee or his/her representative. (Representatives must be designated in writing.) NOTE: The OSHA representatives may also examine and/or copy medical records or medical information from the medical record that may bear directly on exposure to toxic materials or harmful physical agents.
- Arranging for or conducting annual surveillance examinations for employees, as necessary.
- Supervisors. An injured employee's Supervisor (or other official superior) is responsible for:
- Getting prompt medical treatment for an injured employee and advising the employee that his/her rights to compensation and continued treatment are protected.
- Informing the employee that in non-emergency situations a physician or hospital they choose must be within a 25-mile radius of their home or worksite.
- Informing the employee of his/her obligations to return to work as soon as possible.
- Ensuring that the employee has the appropriate forms for filing.
- Having the employee complete a notice of injury or occupational disease/illness.
- Investigating all circumstances related to each claim, securing written statements from witnesses, if any, and controverting COP whenever the circumstances warrant controversion.
- Maintaining weekly contact with the employee.
- Generating a report on the employee's injury, disease/illness, or death; and forwarding a copy of the report to the appropriate safety official.
- Receiving and sending all injury reports, notices, and claims to the SPO within prescribed deadlines for review and transmittal to OWCP.
- Assisting employees and their supervisors in preparing claims.
- Counseling employees on both their FECA rights and responsibilities.
- Sending Form CA-17, "Duty Status Report" to the attending physician on a weekly basis or periodically as necessary to monitor the employee's status and ability to return to light or full duty and to facilitate the injured employee's return to suitable employment; corresponding in writing with the employee's physician about the work limitations and restrictions imposed by the effects of the injury and possible job assignments (a copy of such correspondence must be sent to OWCP and the employee, as well as a copy of the physician's response when received); and, in continuation of pay cases, calling the employee's attending physician if additional information or clarification is needed, provided such contact is by a HHS physician, nurse, or appropriate supervisory official.
- Considering suitable job offers, in consultation with the SPO, when accommodations can be made to the injured employee's medical condition where the attending physician has found the employee partially disabled and the employee is able to (1) perform a specific alternative position, or (2) perform restricted or limited duties.
- Contacting the employee immediately by telephone to inform him/her of the availability of such alternative position or restricted/limited work with a description of the duties and physical requirements; confirming the job offer in writing as soon as possible with the date by which a response to the offer is required; and sending a copy of the offer to the SPO as well as a copy of the employee's response when it is received.
Supervisors will perform their responsibilities working with their respective SPOs, and all actions taken must be in consultation/coordination with their SPO.
- Employees who sustain a work-related injury or suffer an occupational disease/illness are responsible for notifying their supervisor immediately, for completing the required forms as directed within the prescribed deadlines, for advising their attending physician to timely submit medical evidence of disability covering the specific period, and for returning to work or seeking work when able.
- Under normal circumstances, an initial FECA claim form must be submitted to the supervisor within 3 working days following a injury.
- An employee receiving continuation of regular pay or OWCP compensation benefits must report for a medical examination when directed by IHS to determine medical limitations that may affect placement.
- An employee receiving continuation of regular pay has the following specific obligations:
- Where the employee is informed by IHS of the existence of a specific alternative position(s), he/she must send the description of such position(s) to the attending physician and find out whether and when he/she will be able to perform its duties. The employee must give IHS a copy of the physician's response.
- Where the employee is informed by IHS of its willingness to accommodate, where possible, his/her work limitations and restrictions, he/she must tell the attending physician and request the physician to specify the limitations and restrictions imposed by the injury. The employee must then immediately notify IHS of the limitations and restrictions imposed.
- Where the employee has been offered duties within the limitations and restrictions imposed by the attending physician, he/she must return to work. Where the employee refuses the offer of suitable work, entitlement to continuation of regular pay ceases as of the effective date of availability of such work. In addition, the continued absence may result in an overpayment of salary subject to repayment.
- An employee receiving OWCP compensation benefits has the following specific obligations:
- Where the employee is informed by IHS of the existence of a specific alternative position(s), he/she must send the description and physical requirements of such position(s) to the attending physician and find out whether and when he/she will be able to perform its duties.
- Where the employee is informed by IHS of its willingness to accommodate, where possible, his/her work limitations and restrictions, he/she must tell the attending physician and request the physician to specify the limitations and restrictions imposed by the injury. The employee must then immediately notify IHS of the limitations and restrictions imposed.
- Where the employee has been offered suitable employment (including his/her position of record) by IHS as determined by OWCP, he/she must return to such employment. If the employee refuses to do so without reasonable cause as determined by OWCP, compensation benefits may be terminated and the continued absence may be considered unauthorized.
1-8.4 CLAIMS PROCESSING
When a work-connected accident or traumatic injury to an employee occurs, the first concern is to get prompt medical treatment for the employee.
- Emergency Treatment. If emergency treatment is necessary, the health unit, a Federal medical officer or hospital, or any local physician or hospital may be contacted for initial treatment. The employee may choose the physician or hospital of their choice. Ambulatory care and transportation is covered under FECA.
- Non-emergency Treatment. In non-emergency cases, treatment for the employee may be obtained from the health unit, a Federal medical officer or hospital, or from a physician or hospital of the employee's choice with the appropriate authorization from the agency. Generally, the employee may select any physician or hospital within 25 miles of the employee's home or worksite. An employee who wishes to select a physician beyond the 25-mile requirement must contact OWCP for authorization. If the employee later wishes to change physicians, he/she must contact OWCP in writing for authorization and include the reasons for requesting the change. On obtaining treatment, the employee must ask the physician the earliest date that he/she will be able to return to work.
- Health Units. Health units are available primarily to provide emergency diagnosis and initial treatment of an injury or illness. Subsequent treatments by the health unit for a work-related injury must be approved by the physician providing medical care under the specific authorization of OWCP.
- Exclusion of Certain Medical Providers. Providers who have been convicted under a criminal statute for fraudulent activities in connection with a Federal or State program are automatically excluded from participation in the FECA program. The OWCP maintains a current list of excluded providers.
- Authorization of Medical Treatment. Supervisors are responsible for authorizing prompt medical treatment of the injured employee. In authorizing medical care, the OWCP regulations require the supervisor to issue Form CA-16, "Authorization For Examination and/or Treatment," within 4 hours of the time the need for medical treatment is recognized by the supervisor. Normally, the Form CA-16 can be issued within a few minutes of the request. If the supervisor finds cause to refuse a request for Form CA-16, the employee should be told the reason within the 4-hour period (e.g., a CA-16 may be refused if more than a week has passed since the injury on the basis that the need for immediate treatment would normally have become apparent in that period of time). In an emergency, where there is no time to complete a Form CA-16, the supervisor may authorize medical treatment by telephone and then send the completed Form CA-16 to the attending physician/hospital within 48 hours of the initial examination or treatment. Retroactive issuance of Form CA-16 is not permitted under any other circumstance. The supervisor must send a copy of the Form CA-16 to the personnel office. The employee should also be given a copy of Form OWCP-1500, "Health Insurance Claim Form," which is used for billing by the attending physician. Copies of Form OWCP-1500 may be obtained from the administrative office and/or the personnel office.
- It is not necessary for a supervisor to issue a Form CA-16 when an employee goes to a health unit that authorizes outside referral.
- In completing the Form CA-16, the supervisor should check Box B1 of Item 6 if he/she has personal knowledge that the employee was injured in the performance of duty. When this box is checked, the form authorizes all necessary treatment with the exception of elective surgery.
- Box B2 of Item 6 is checked when there is doubt as to whether the disability was caused by a work-related traumatic injury. This will authorize only necessary diagnostic studies and emergency treatment pending a determination by OWCP. If OWCP later determines that the condition for which the studies or treatment was rendered is not due to an injury, the supervisor will immediately tell the employee and the physician/hospital that no further service will be rendered at the expense of OWCP.
- The Form CA-16 is valid for 60 calendar days from the date of issuance. The original treating physician may wish to refer the employee for more specialized treatment or for further testing. He/she may do so on the basis of the Form CA-16 already issued; it is not necessary to issue additional authorizations for treatment. The original physician (or any physician to whom the employee is referred) is guaranteed payment for 60 days from the date of issue of Form CA-16 unless OWCP terminates this authority at an earlier date. The employee, however, continues under treatment without further explicit authorization after the initial 60 calendar days unless OWCP has denied benefits or has issued a letter rescinding authorization.
- Reporting the Injury. In addition to authorizing necessary medical treatment, a written report of the injury is required. The employee must give written notice of the injury to the supervisor as soon as possible, but not later than 30 calendar days after the injury to avoid possible interruption of pay and must show whether the employee elects to use sick and/or annual leave or continuation of regular pay.
The employee and/or someone acting on his/her behalf, including a family member, union official, or IHS official must obtain a Form CA-1, "Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation," from the supervisor. The CA-1 serves as the written report. The supervisor will also provide a copy information sheet, "Instructions for Federal Employees for Traumatic Injury Claims under the Federal Employees' Compensation Act (FECA) which is attached to the CA-1. The Form CA-1 must contain the original signature of the person giving notice. If notice is not submitted within 30 calendar days following the injury, the employee may be denied compensation benefits to which he/she is otherwise entitled. When the notice of injury is completed by the employee, the supervisor will complete the Receipt of Notice of Injury that is attached to the form and give the receipt to the employee. The supervisor will obtain statements from any witnesses. The employee must submit the notice of injury even if it did not require medical treatment in order to protect his/her rights to compensation in the future.
The supervisor is required to submit a written report of the injury to the SPO using the Form CA-1 as soon as possible, but no later than 5 workdays after receipt from the employee, especially if the injury is likely to result in one of the following:
The supervisor sends the completed Form CA-1, together with the report of any investigation made and any other statements or data that may properly relate to the circumstances of the injury, to the SPO for transmittal to OWCP. Where the supervisor has reason to disagree with any particular portion of the injury as reported by the employee, he/she will explore the circumstances of the injury and include with the Form CA-1 a full written explanation specifying the areas of disagreement and the findings on which the disagreement is based (if written explanation in support of the disagreement is not submitted, OWCP may accept as factual the report of injury made by the employee)
The SPO will review the claim for completeness and accuracy and record any filing omissions (e.g., medical report not yet received and attached) before forwarding to the OWCP district office serving that component.
When the Form CA-1 is received by OWCP, they will send a postcard (Form CA-801) to the injured employee and IHS that shows the claim number assigned to the case.
If the reported injury does not meet the conditions stated above, then the original Form CA-1 will be sent to the personnel office rather than to OWCP. The personnel office will file the form in the employee's OWCP case monitoring file.
- A medical charge
- Disability for work beyond the day or shift when the injury occurred
- Prolonged treatment (i.e., more than two instances of medical examination and/or treatment)
- Future disability
- Permanent impairment
- Continuation of pay
- Initial Advice to Employee about Pay Status.
- If the injury disables the employee for work beyond the day when the injury occurred, the supervisor will inform the employee of the right to elect continuation of regular pay (for up to 45 calendar days) or to use sick and/or annual leave. The supervisor will inform the employee of the provisions relating to continuation of regular pay. The employee, or someone acting on his/her behalf, must certify on the Form CA-1 whether the employee elects to use sick and/or annual leave or continuation of regular pay.
- The supervisor should inform the employee that continuation of regular pay is his/her normal pay from IHS, subject to taxes and all the other payroll deductions.
- The supervisor should inform the employee that if he/she elects to use sick/or annual leave during the initial 45-day period instead of continuation of regular pay, he/she may later request continuation of regular pay in lieu of previously used annual and/or sick leave provided such request is made within 1 year of the date the leave was used or the date OWCP approved the claim, whichever is later. The use of leave may not be used to delay or extend the 45-day continuation of regular pay period. Therefore, where leave is used during a period when continuation of regular pay is otherwise payable, and the employee does not request that such leave be converted and restored, the 45 days will be counted as though he/she has been in a continuation of regular pay status.
- Continuation of Regular Pay (COP).
- When an employee suffers a work-related traumatic injury and is disabled for work, the regular pay of the employee may be continued for a period not to exceed 45 calendar days. The 45-day period starts at the beginning of the first full day or first full shift when the disability begins, or if the employee was not immediately disabled as a result of the injury, the first full day or shift when disability begins.
- The supervisor will inform the employee of his/her responsibility to submit prima facie medical evidence of disability within 10 workdays of notification or risk termination of COP.
- The supervisor will, on the basis of information submitted by the employee or secured on investigation controvert or dispute an employee's claim for COP and terminate COP only if one of the following conditions apply:
- The disability is a result of an occupational disease/illness and not of a traumatic injury.
- The injury occurred off the employing organization's premises and the employee was not engaged in official "off premise" duties.
- The injury was caused by the employee's willful misconduct; the employee intended to bring about the injury or death of himself/herself or another person; or the employee's intoxication by alcohol or illegal drugs was the proximate cause of the injury.
- Work stoppage first occurred more than 90 days following the injury.
- The employee initially reports the injury after his/her employment has terminated.
- The injury was not reported on Form CA-1 within 30 calendar days following the injury.
- The employee is other than a citizen or resident of the United States or Canada.
- The employee works without pay or for nominal pay and is excluded by the FECA from the COP benefit.
- The employee is enrolled in the Civil Air Patrol, Peace Corps, Job Corps, Youth Conservation Corps, Work Study Programs, or other similar groups.
- If the supervisor is going to controvert or dispute the employee's COP, he/she should tell the employee the basis for the action and whether pay will be terminated.
- In cases other than those listed in l-8.4H(3) above, the supervisor may controvert an employee's right to COP, but the employee's pay will not be interrupted during the 45-day period unless OWCP sustains the controversion and so notifies IHS. The OWCP will notify IHS if the COP should be recovered or charged to leave.
- The supervisor may controvert the employee's claim by completing the applicable portion of Form CA-1 and submitting it to OWCP along with supporting information.
- The employee's COP will be terminated when one of the following occurs:
- The supervisor has not received prima facie medical evidence of injury-related disability within the 10-workday period after the employee claims COP or the disability begins (or recurs), whichever is later. Pay may be continued without such evidence if the supervisor is satisfied that the employee sustained a disabling traumatic injury. When the medical evidence is received after the 10-workday period, the COP must be continued retroactive to the date the COP was terminated, provided the medical evidence supports the injury-related disability.
- The supervisor receives medical information from the attending physician to the effect that the employee is no longer disabled for work (i.e., employee can perform the duties of the position held at the time of injury).
- The supervisor receives evidence that the attending physician has found the employee partially disabled during the COP period and the employee refuses suitable work that has been offered by IHS or fails to respond to such offer within 5 workdays of receipt of the offer.
- The supervisor receives notification from OWCP that pay should be terminated.
- The 45 calendar day period has expired.
- The employee's scheduled period of employment ends or employment is otherwise terminated (when a employee who is scheduled to be separated reports an traumatic injury on or before the separation, he/she separates from employment as scheduled but is entitled to COP up to the date of separation and to compensation thereafter).
- Supervisors are responsible for verifying the right of employees to elect COP and the dates on which COP applies. They also are responsible for telling timekeepers the purpose of reporting COP.
- Timekeepers will document COP on the employee's time card according to instructions issued by the Division of Central Payroll, which includes how to count COP days when employee is in light duty status.
- When COP ends, the supervisor must complete Form CA-3, "Report of Termination of Disability and/or Payment," and send it to the SPO for transmittal to OWCP. Form CA-3 is also completed and submitted to inform OWCP of the date that the employee returned to work or his/her disability ceases.
- Claim for Compensation if Disabled for Work Beyond 45 Days COP.
- The special procedures below should be followed in all cases where there is a possibility the employee may not be able to resume work at the end of the 45 days COP and he/she elects compensation and not use of leave. These special procedures are designed to avoid interruption of pay before injured employees receive their first compensation payment from OWCP.
- After 30 days of COP:
The supervisor should begin preparations to submit a wage loss claim to OWCP by giving Form CA-7, "Claim for Compensation on Account of Traumatic Injury or Occupational Disease," to the injured employee with instructions to complete Part A and to return the form to the supervisor within 7 calendar days.
The supervisor will inform the employee that OWCP consideration of the claim will depend on timely submission of the Form CA-7 and the timely submission by the physician of medical evidence of disability for work for a specific period. The employee is responsible for submitting, or arranging for the submission of, medical evidence in support of the claim. Form CA-20 is attached to Form CA-7 for this purpose. The supervisor should insert the OWCP address in the box on the reverse side of the Form CA-20. The physician should send the completed Form CA-20 directly to OWCP with a copy to the SPO.
- After 40 Days of COP:
If the Form CA-7 has not been returned, the supervisor should telephone the employee and request immediate submission of the form.
If the employee has not returned to work by the 40th day of COP, the supervisor should complete the rest of the form and send the completed Form CA-7 to the SPO for transmittal to OWCP (any new medical evidence available to IHS should also be included).
- The pay rate on the date of injury and the date the employee stopped work should be shown in Block 20. The claim should not be delayed for computations of shift differential, Sunday, or holiday pay, etc. This additional pay data can be submitted separately as soon as it is computed.
- The period of time covered by the Form CA-7 (Blocks 4 and 31) should be the period of disability supported by the medical evidence or the period up to the employee's next scheduled medical appointment. For example, if the 45-day COP period ends March 31 and current medical evidence covers employee through April 15, the dates in Blocks 4 and 31 would be April 1, through April 15.
If the employee resumes work after Form CA-7 has been submitted, the supervisor should immediately notify the SPO who in turn will notify OWCP and complete a Form CA-3, "Report of Termination of Disability and/or Payment," to verify the return to work. Telephone notification is critical to avoid overpayment. The supervisor sends the completed Form CA-3 to the personnel office for transmittal to OWCP.
- Ten Days Before CA-7 Period Expires:
If disability is expected to continue beyond the period claimed on the Form CA- 7, the supervisor should give the injured employee a Form CA-8, "Claim for Continuing Compensation on Account of Disability", with instructions to complete Blocks 1 through 14 and to return the form to the supervisor within 5 calendar days of receipt of the CA-8.
- Five Days Before CA-7 Period Expires:
The supervisor should complete the rest of Form CA-8 and send it to the SPO for transmittal to OWCP at least 5 calendar days before the CA-7 period ends. The period of time covered by the Form CA-8 (Block 6) should be the period of disability supported by the medical evidence or the period up to the employee's next scheduled medical appointment. For instance, continuing the example given above, if new medical evidence indicates employee will be absent through April 30, the dates in Block 6 would be April 16 through 30.
The employee is responsible for submitting, or arranging for the submission of medical evidence in support of the claim. Form CA-20a is attached to Form CA-8 for this purpose. The supervisor should insert the OWCP address in the box on the reverse side of the Form CA-20a. The physician should send the completed Form CA-20a directly to OWCP with a copy to the SPO.
- Continuing Disability for Work:
When disability is expected to continue, and until informed by OWCP that employee has been placed on its regular compensation roll, the supervisor should continue to obtain and submit Form CA-8 to OWCP every two weeks. This should be done at least 5 calendar days before the end of the period claimed on the preceding Form CA-8.
The employee continues to be responsible for submitting or arranging for the submission of medical evidence in support of the claim (using Form CA-20a).
- The employee should be informed that when he/she is disabled for work and the claim for compensation is approved, he/she receives compensation at the rate of 66 2/3 percent of the employee's established pay rate. The compensation rate is increased to 75 percent when there are one or more dependents. The employee should also be advised to notify OWCP of any event that would terminate his/her continued entitlement to any augmented compensation. Disability compensation payments are subject to the sick pay exclusion provision of the Internal Revenue Code.
- Employees must be in a non-pay status for 3 calendar days before they are entitled to disability compensation payments. If the non-pay status continues for 14 calendar days or the injury results in permanent disability, then employees will be paid for the 3 day waiting period. Compensation may not be paid while injured employees receive pay for leave or are otherwise in a COP status. Therefore, the employee must be on leave without pay (LWOP) to receive compensation from OWCP. An employee requests LWOP on Standard Form 71, "Application for Leave."
- Employees have the right to elect to receive pay for sick and/or annual leave or to receive compensation following the 45-day COP period. If the employee decides to use sick and/or annual leave at the end of the 45-day COP period instead of LWOP to avoid interruption of income, he/she may later request to "buy back" the leave used if the claim for compensation is subsequently approved by OWCP. Section 13 contains the full details on "buy back" procedures.
- Return to Work After Being Disabled.
- Whenever a disabled employee returns to work or disability ceases, the supervisor must notify the SPO who in turn notifies OWCP immediately by submitting Form CA-3, "Report of Termination of Disability and/or Payment." The supervisor sends the completed Form CA-3 to the SPO for transmittal to OWCP.
- A disabled employee who recovers within 1 year is entitled by law to return to his/her former position or an equivalent position.
- Excused Absence for Examination or Treatment for Injury/Disease/Illness.
- Work time lost by the employee on the day or shift on which the injury occurred will be excused without charge to leave. This is administrative leave or excused absence.
- If the injured employee is not disabled for work (or has returned to work), any COP available may be used for subsequent examinations or treatments authorized by OWCP (i.e., provided no more than 90 calendar days have elapsed since the date of first return to work, including return to part-time work or light duty, following the first work stoppage). Otherwise, sick leave, annual leave, or LWOP may be granted; the employee may then apply to OWCP for compensation or leave buy-back for the period involved. Form CA-7 may be used for this purpose. Leave-approving officials may require the employee to submit medical documentation for such examinations and treatments.
- Recurrence of Disability.
- If the employee has returned to work and the same injury then causes some additional work stoppage, the supervisor is required to notify OWCP. A recurrence is distinguished from a new injury by the criterion that in a recurrence no event other than the previous injury accounts for the disability. Follow-up medical care for an injury or disease/illness which causes lost time is considered part of the original injury rather than a recurrence unless the employee was previously released from treatment. Form CA-2a, "Federal Employee's Notice of Disability and Claim for Continuation of Pay/Compensation," must be completed promptly by the supervisor after the employee completes his/her part of the form and sent to the SPO for transmittal to OWCP.
- The employee should arrange for submission of the factual and medical evidence described in the instructions attached to the Form CA-2a, paying particular attention to the need for bridging information which describes his/her condition and job duties between the original injury and the recurrence.
- If the employee is entitled to use COP and the 45 calendar days of COP have not been exhausted, he/she may elect to use the remaining days if 90 days have not elapsed since first return to duty. If the recurrence begins later than 90 days after the first return to work, COP is not paid even though some days of entitlement remain unused. A period which begins before the 90 day deadline and continues beyond it, however, may be charged to COP as long as the period of time is uninterrupted. The employee may elect to use sick and/or annual leave and/or request LWOP and claim compensation pending adjudication of the claim for recurrence. If an employee wishes to claim compensation, Form CA-7 is required if one was not previously submitted. If a Form CA-7 was submitted, then the employee is to complete a Form CA-8 and submit it to the supervisor along with supporting medical evidence. A Form CA-8 is to be completed and submitted every 2 weeks.
- If the recurrent disability has not ended at the time the Form CA-2a is submitted, a Form CA-3 must be sent to OWCP when the employee returns to work.
- The supervisor, at his/her discretion, may issue Form CA-16 to authorize examination or treatment for a recurrence of disability if it resulted from an injury previously recognized as compensable by OWCP. The supervisor may not authorize examination or treatment when OWCP has disallowed the original claim or when more than 6 months have elapsed since the employee last returned to work. In any case where there may be doubt that the symptoms or disability are the result of the injury, or where it has been more than 6 months since the last return to work, the supervisor must communicate with their SPO and request instructions, stating all the pertinent facts. In all other cases, the employee must communicate with OWCP and request such treatment.
- OCCUPATIONAL DISEASE OR ILLNESS PROCEDURES.
- Reporting the Disease or Illness.
When a supervisor is notified that an employee wishes to file a claim for occupational disease/illness, the following initial actions should be taken:
- The supervisor will provide the employee with Form CA-2, "Notice of Occupational Disease and Claim for Compensation," for reporting the disease/illness. The supervisor will provide a copy of the information sheet, "Instructions for Federal Employees for Occupational Disease Claims under the Federal Employee's Compensation Act (FECA)," which is attached to the CA-2. If the employee is unable to report the disease/illness, the notice may be given by anyone acting on his/her behalf. The Form CA-2 must contain the original signature of the person giving notice. The Form CA-2 must be submitted by the employee within 30 calendar days from the date on which he/she was first aware, or by the exercise of reasonable diligence should have been aware, of a possible relationship between the disease/illness and the conditions or factors of his/her employment. Failure to give notice within this time period may result in a loss of compensation rights. Only in rare instances is medical care authorized by the supervisor in occupational disease/illness claims. Where the disease/illness is sufficiently severe to warrant immediate medical attention, the supervisor must obtain prior permission from OWCP (by telephone, if urgent) to issue a Form CA-16, "Authorization for Examination and/or Treatment." If the Form CA-16 is issued, Box B2 of Item 6 is checked.
- At the same time the employee receives Form CA-2, the supervisor will provide 2 copies of the correct Occupational Disease Checklist to speed up processing of the claim. The OWCP developed the checklists to tell both the employee and the supervisor what factual information is required before medical questions can be explored. There are special checklists for seven conditions that are commonly claimed and an eighth checklist for use when questions arise about other conditions, or when the nature of the problem is not fully known: CA-35a General Checklist; CA-35b Hearing Loss; CA-35c Asbestos; CA-35d Coronary/Vascular Conditions; CA-35e Skin Diseases; CA-35f Pulmonary/Respiratory (not asbestosis related); CA-35g Psychiatric Illness; CA- 35h, Carpal Tunnel Syndrome. The supervisor will inform the employee that the checklist provides a convenient list of information which must be provided to OWCP to support the claim. The information on the left side is provided by the employee; the information on the right side is collected and submitted by IHS (supervisor, administrative office, personnel office). The supervisor will inform the employee that medical information will be required from a physician to support the claim.
- The supervisor should take steps to get the information required from IHS, using the checklist as a guide. When the employee returns the completed Form CA-2 with statements and other documents, the supervisor will:
- Review the employee's portion of Form CA-2 for completeness and accuracy and assist the employee in correcting any deficiencies found.
- Compare the employee's documents with the checklist, and remind the employee if anything is missing. The checklist can be marked to show what is being provided by checking the box to the right of each item. If something must be sent later, the date should be inserted in the box.
- Give the employee the signed and dated receipt portion of the Form CA-2.
- Have the employee's statement about work factors reviewed by one or more persons who can comment on its accuracy and completeness. Their statements should be attached to this package. The SPO must review the claim for completeness prior to submission to OWCP.
- Complete the supervisor's portion of Form CA-2. Attach a narrative or supporting statement as required by CA-2 instructions and include all of the requested information such as exposure data, test results, copies of previous medical examinations, and the like, depending on the nature of the case.
- Send the completed Form CA-2 with all the collected information to the SPO for transmittal to OWCP within 5 workdays of receipt from the employee. The CA-2 must be submitted to OWCP within 10 days. It should not be held beyond that time pending receipt of any supporting documentation. If the whole package is not ready, send what is ready and indicate on the checklist when the rest is coming.
Be sure to supply the address and telephone number where someone familiar with the claim may be reached. When the CA-2 is received by OWCP, they will send a postcard (Form CA-801) to the injured employee and IHS that shows the claim number assigned to the case.
- Explore the circumstances of any case where he/she has reason to disagree with any particular of the occupational disease/illness as reported by the employee and submit a full written explanation to their SPO who will then forward it to OWCP within 30 calendar days, specifying the areas of disagreement and the findings on which the disagreement is based (if written explanation in support of the disagreement is not submitted, OWCP may accept as factual the report of occupational disease/illness made by the employee). This disagreement provision does not change or delay the requirement that Form CA-2 is to be submitted to OWCP within 10 days.
- If Disabled for Work.
- If the disease/illness disables the employee for work, the supervisor will inform the employee of the right to elect to receive pay by using his/her sick and/or annual leave or to receive compensation from OWCP. The employee must be on leave without pay (LWOP) to receive compensation from OWCP. An employee requests LWOP on Standard Form 71, "Application for Leave." An employee disabled for work as a result of an occupational disease/illness is not eligible for the 45-day COP benefit.
- For the employee to claim compensation for pay lost because of disability for work, the employee and the supervisor must complete Form CA-7, "Claim for Compensation on Account of Traumatic Injury or Occupational Disease." The form should be filed with their SPO within 5 calendar days after pay stops, or when the employee returns to work if the pay loss was less than 10 days. The maximum time limit for filing a claim for disability compensation is 3 years after the onset of the disease/illness. The SPO, after reviewing the CA-7, will then transmit the CA-7 to OWCP within 5 days of receipt.
- In addition to the Form CA-7, Form CA-20, "Attending Physician's Report," showing disability for work, must also be submitted to OWCP. The employee is responsible for submitting or arranging for the submission of the Form CA-20. The supervisor should insert the OWCP address in the box on the reverse side of the Form CA-20. The physician should send the completed Form CA-20 directly to OWCP and a copy to SPO.
- The 3 waiting period in non-pay status required before an employee is entitled to disability compensation payments also applies to employees disabled for work by occupational disease or illness.
- The disability compensation payment benefits described for employees who have a traumatic injury apply to employees disabled for work by occupational disease/illness.
- If the employee decides to use sick and/or annual leave instead of LWOP to avoid interruption of income, he/she may later request to "buy back" the leave used if the claim for compensation is subsequently approved by OWCP. Section 13 contains the full details on "buy back" procedures.
- Continuing Disability for Work.
If an employee is disabled for work for a continuing period of time beyond the period for which compensation is claimed on the Form CA-7, the employee and supervisor must complete Form CA-8, "Claim for Continuing Compensation on Account of Disability." The specific steps outlined in under "Continuing Disability for Work" (traumatic injury) are also to be followed for continuing disability due to occupational disease/illness.
- Return to Work After Being Disabled.
- Whenever a disabled employee returns to work or disability ceases, the supervisor must notify OWCP immediately by submitting Form CA-3, "Report of Termination of Disability and/or Payment." The supervisor sends the completed Form CA-3 to the SPO for transmittal to OWCP.
- A disabled employee who recovers within one year is entitled by law to return to his/her former position or an equivalent position.
- Absence for Examination or Treatment.
If the employee has an occupational disease/illness but is not disabled for work (or has returned to work), absences for examinations or out-patient treatment authorized by OWCP will be charged to LWOP, annual leave, or sick leave; the employee may then apply to the OWCP for compensation or leave buy-back for the period involved. The Form CA-7 may be used for this purpose. Leave-approving officials may require the employee to submit medical documentation for such examinations or treatments.
- Recurrence of Disability for Work.
- If the employee has returned to work and the same disease/illness then causes some additional work stoppage, the supervisor is required to notify OWCP. The Form CA-2a, "Federal Employee's Notice of Recurrence of Disability and Claim for Continuation Pay/Compensation," must be completed promptly by the supervisor after the employee completes his/her part of the form and sent to the SPO for transmittal to OWCP.
- The employee may elect to use sick and/or annual leave and/or request LWOP and claim compensation pending adjudication of the claim for recurrence. If an employee wishes to claim compensation, Form CA-7 is required if one was not previously submitted.
- If a Form CA-7 was submitted, then the employee is to complete a Form CA-8 and submit it to the supervisor along with supporting medical evidence. A Form CA-8 is to be completed and submitted every 2 weeks.
- If the recurrent disability has not ended at the time the Form CA-2a is submitted, a Form CA-3 must be sent to OWCP when the employee returns to work.
- The supervisor and SPO's monitoring efforts will be to determine the earliest date when an employee may do one of the following:
- Return full-time to the position held at the time of injury.
- Return part-time to regular duties.
- Return full-time or part-time to perform with reasonable accommodation the essential functions of the position held at the time of the initial claim or to a light-duty assignment.
- Be offered a different job or a restructured job as a partially disabled employee.
- When the SPO, in consultation with the supervisor, and a medical professional determines that a second medical opinion should be sought, the SPO will contact the OWCP district office to request arrangement of a second medical examination.
- When the SPO, in consultation with a supervisor, determines that an investigation of possible waste, fraud, or abuse should be sought, the SPO will request an investigation by the appropriate DOL investigator or the HHS Office of Inspector General (OIG).
- The result of seeking a second medical opinion or OIG investigation of possible waste, fraud, or abuse will be forwarded, as appropriate, to one of the following:
- The supervisor and SPO may include recommendation ranging from terminating COP to merely providing more thorough or timely reports.
- The OWCP district office may include recommendations ranging from a request to terminate benefits to merely requesting more careful review of reports being forwarded.
- Each Area Office will establish a system for periodic review of all FECA cases for which that Area Office is billed but where the recipient is no longer on Agency rolls.
- For each such case, the Area will arrange for periodic on-site reviews of the case file at the appropriate OWCP district office. (See Exhibit 1-8-B).
- Where it appears that a new medical report might reveal partial recovery sufficient to allow a light duty or alternative work assignment, the SPO will request the OWCP district office to arrange for a medical examination.
- Any report of partial recovery will be returned to the SPO for renewed action in locating an appropriate light-duty or alternative work assignment for which rehiring would be offered to the employee.
1-8.6 FORMS, RECORDS, AND OTHER INFORMATION
- Supply of Forms.
The SPO must maintain and provide a supply of the forms listed below to supervisors as needed:
- Form: CA-1 Title: Federal Employees' Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
- Form: CA-2 Title: Notice of Occupational Disease and Claim for Compensation
- Form: CA-2a Title: Federal Employees' Notice of Recurrence of Disability and Claim for Continuation of Pay/Compensation
- Form: CA-3 Title: Report of Termination of Disability and/or Payment
- Form: CA-5 Title: Claim for Compensation by Widow, Widower, and/or Children
- Form: CA-5a Title: Claim for Compensation by Parents, Brothers, Sisters, Grandparents or Grandchildren
- Form: CA-6 Title: Official Supervisor's Report of Employee's Death
- Form: CA-7 Title: Claim for Compensation on Account of Traumatic Injury or Occupational Disease
- Form: CA-8 Title: Claim for Continuing Compensation on Account of Disability
- Form: CA-16 Title: Authorization for Examination and/or Treatment
- Form: CA-17 Title: Duty Status Report
- Form: CA-20 Title: Attending Physician's Report
- Form: CA-20a Title: Attending Physician's Supplemental Report
- Form: OWCP-1500 Title: Health Insurance Claim Form
- Form: OWCP-1500a Title: Instructions for Completing the Health Insurance Claim Form
The SPO will maintain supplies of occupational disease claims processing "checklists" that are available from DOL. These claim forms are to be reproduced locally by the SPOs.
Completion of Forms.
Each form contains instructions for completing that particular form. Instructions for filling out the forms are attached to the form.
The OWCP/DOL is reimbursed by each HHS component for benefits paid to the component's employees. In order that the correct account may be charged, all completed forms must show employment by HHS, the appropriate organization component within HHS, and the OWCP Agency Code. The OWCP Agency Code for IHS is 1215, followed by an alpha in accordance with your Area, which is inserted on the claims forms by the SPO.
Before forwarding any claims to DOL/OWCP, it is the responsibility of each SPO to ensure that the appropriate OWCP Agency Code is entered onto the OWCP form so that each Area Office is properly billed. The Agency Codes for IHS are:
- Code: 1215 Location:
HQ East - Rockville & Perry Point, MD
HQ West - Albuquerque, NM
Clinical Support Center - Phoenix AZ
- Code:1215A Location: Office of Health Programs and Research Development, Tucson AZ
- Code:1215B Location: Aberdeen Area
- Code:1215C Location: Alaska Area
- Code:1215D Location: Albuquerque Area
- Code:1215E Location: Bemidji Area
- Code:1215N Location: Billings Area
- Code:1215G Location: California Area
- Code:1215H Location: Nashville Area
- Code:1215J Location: Navajo Area
- Code:1215K Location: Oklahoma City Area
- Code:1215L Location: Phoenix Area
- Code:1215M Location: Portland Area
Medical Reports Required.
- A SPO FECA case monitoring file (separate from an employee's medical folder) will be established for each FECA case forwarded to the SPO by a supervisor, by a health unit medical officer, by a safety management official, etc. An individual employee's FECA case monitoring file will include:
- Official records- -copies of official OWCP forms received from that employee (or employee's supervisor) for filing or transmittal to OWCP; references to FECA claim related medical reports added to the employee medical file; copies of requests from OWCP for supplemental information, etc.
- Case-management and monitoring efforts-- attempts to locate light-duty or alternative work assignments for that employee; copies of communication to and from the employee's physician seeking medical certification of sufficient recovery to perform proposed light-duty or alternative work assignments; copies of communications to and from OWCP concerning requests for second medical examinations or reassignment of case responsibility; copies of communications to and from the employee concerning specific offers of light-duty or alternative work; copies of SF-50B's, "Notice of Personnel Actions," implementing temporary work assignments; etc. FECA case files will be preserved in the SPO.
- When the treatment or examination received by the employee is at a PHS/IHS facility and is directly related to an on-the-job injury or occupational illness, the record of treatment must be made part of the EMF.
- When an IHS employee uses an IHS facility for which he/she is employed for treatment of an occupational injury, illness, or disease, the doctor's report of the visit must be filed in the appropriate section of the employee's medical file.
In all cases reported to OWCP, supervisors will furnish the necessary medical forms to the employee or treating physician (Form CA-16). The physician's original signature must appear on the report form in all instances. The following forms are to be used as appropriate:
Compensation for Partial Disability or Loss of Body Member or Organ.
- Part B of the Form CA-16 authorizing the medical treatment is to be completed by the physician to provide OWCP with initial medical reports;
- Form CA-17, "Duty Status Report," is used when the employee is disabled for work to provide the supervisor and OWCP with weekly reports from the physician on the employee's medical condition (or periodically as necessary). The supervisor completes his/her portion of the form by describing the physical requirements of the employee's job, noting the availability of any light work, and then sends the form to the attending physician. The physician completes his/her portion of the form and sends the original back to the supervisor to monitor the employee's medical status and ability to return to light or full duty. The supervisor provides the SPO with a copy of the completed form.
- Form CA-20, "Attending Physician's Report," comes attached to CA-7 and is used to provide OWCP with medical information regarding an employee's claim for compensation and may also be used for the initial report.
- Form CA-20a, "Attending physicians Supplemental Report," comes attached to Form CA-8 and is used to provide OWCP with additional medical information regarding an employee's claim for continuing compensation.
In addition to completing the forms, the treating physicians are required to make detailed supplementary reports in narrative form at approximately monthly intervals in all cases of serious injury or disease/illness, especially injuries of the head and back, and including all cases requiring hospital treatment or prolonged care. Copies of all medical reports submitted directly to OWCP will be requested by IHS from OWCP. The full details on these specific requirements are in the OWCP regulations.
Compensation may be provided when an employee suffers the work-related loss of a body member or organ or is unable to return to usual employment because of partial disability. In some cases, the loss of certain body members or organs may constitute a permanent total disability. The claim for compensation should be submitted according to the instructions on Form CA-7.
INJURY OR DEATH WHILE IN TRAVEL STATUS.
Employee Status While Receiving Injury Compensation.
- Within the United States.
Any employee going on official travel within the United Sates should be informed that, if injured, they are to telephone their supervisor or have someone do it for them.
The telephone caller is to give the supervisor the name of the physician and/or hospital treating the employee. The employee is to subsequently submit a written notice of the injury.
The supervisor is responsible for authorizing medical treatment.
- Foreign Travel.
An employee injured while on foreign travel is to contact the nearest American Consulate, Embassy, or United Sates installation. When the supervisor is informed of the employee's injury or disease/illness, the supervisor will immediately contact their SPO who will then contact OWCP for instructions on how to proceed.
- Death while in Travel Status.
If death results from a work-related injury or disease/illness while the employee is in official travel status or while in travel status at the direction of OWCP to receive medical services, OWCP is authorized to pay the necessary and reasonable expenses to transport the remains to the employee's home or last place of residence.
Employees who are receiving injury compensation should be carried on leave without pay (LWOP) for at least the first year they are receiving compensation. An employee who recovers within 1 year is entitled by law to return to his/her former position or an equivalent position.
Payment of Expenses.
- When an employee dies as a result of a work-related traumatic injury or an occupational disease/illness, the supervisor must immediately report the death to OWCP through the personnel office. The death is to be initially reported to OWCP by telephone or telegram.
- Form CA-6, "Official Supervisor's Report of Employee's Death is then completed by the supervisor and submitted, promptly to the SPO for transmittal to OWCP. The report of death must be submitted as soon as possible but no later than 10 workdays, after the supervisor's receipt of knowledge of the death. (When Form CA-6 is used to report a death, it eliminates the need for the supervisor to complete his/her portion of the Form CA-1 or 2).
- A sum not to exceed $800 may be paid for funeral and burial expenses, with an additional sum of $200 paid to the personal representative of the decedent for reimbursement of the costs of termination of the decedent's status as an employee of the United States.
- The supervisor should contact any survivors and provide them with "Claim for Compensation for Death" forms, and help them in preparing the claim as much as possible. The forms should be submitted even if a disability claim had previously been filed and benefits were paid. Continuation of benefits is not automatic, as it must be shown that the death resulted from the same condition for which the disability claim was accepted.
- Dependents may claim compensation for the employee's death by filing Form CA-5, "Claim for Compensation by Widow, Widower and/or Children," or Form CA-5b, "Claim for Compensation by Parent, Brothers, Sisters, Grandparents, or Grandchildren." The survivor should complete the front of the appropriate form, while the attending physician should complete the medical report on the reverse and forward it to OWCP. The submission should include a copy of the death certificate which has been certified by the issuing authority. It should also include a certified marriage certificate if a spouse is making claim, and a copy of any divorce or annulment decree if the decedent or spouse was formerly married. Certified copies of birth certificates of any children for whom claim is made should also be included. Since these forms are usually not stocked locally and are usually sent by OWCP to the supervisor only after that office receives the Form CA-6, it is vital that the supervisor process the notice of death promptly. The person claiming compensation should do so within 30 days, if possible, but not later than 3 years after death.
Buy Back of Sick and/or Annual Leave.
- Medical Expenses.
Charges by a physician or provider for medical and surgical treatment, appliances, or supplies must be itemized on American Medical Association (AMA) standard "Health Insurance Claim Form," Form OWCP-1500 (also called HCFA-1500). Charges by hospitals, pharmacies, and nursing homes may be itemized on billhead stationary. All charges must be supported by medical or other required evidence, as applicable. Bills should be submitted directly to OWCP. If the employee pays for such charges, he/she may claim reimbursement; the claim requires an identical submission as above, together with evidence that payment was received and the amount. The OWCP will reimburse the employee and providers for bills received. However, no bill will be paid for expenses incurred if the bill is submitted more than 1 year beyond the calendar year in which the expense was incurred or the service or supply was provided, or more than 1 year beyond the calendar year in which the claim was first accepted by OWCP as compensable, whichever is later.
- Travel Expenses.
When travel is necessary to receive medical care, the injured employee may be furnished transportation and may be reimbursed for travel and incidental expenses. Claim for all travel expenses may be submitted to OWCP on Standard Form 1012.
An employee may decide to use sick and/or annual leave to avoid possible interruption of income in cases of traumatic injury following the 45-day COP period or in cases of occupational disease/illness. The OWCP regulations concerning leave "buy back" are as follows:
Relationship to Health Benefits and Civil Service Retirement.
- If the employee uses leave during a period of disability caused by a traumatic injury, and a claim is approved by OWCP, he/she may "buy back" leave taken after the 45-day COP period subject to the approval of HHS (the employee may not "buy back" leave taken during the 45-day COP period unless he/she was not entitled to receive COP).
- If the employee uses leave during a period of disability caused by an occupational disease/illness, and a claim for compensation is approved by OWCP, he/she may "buy back," the leave taken subject to the approval of HHS.
- If HHS does not approve a "buy back" of leave, then no compensation will be paid for the period leave was taken. Where HHS agrees to the leave "buy back" the employee may elect one of the following:
- He/she may refund to HHS the amount of leave pay received for the period involved. After this refund is made, the Department will change the leave record (from sick and/or annual as the case may be) to LWOP. The employee is then eligible to receive a check from OWCP for the proper amount of compensation.
- If he/she cannot refund the entire amount as required in (a) above, the OWCP, on the employee's authorization, will pay the proper compensation directly to HHS. The OWCP will do this only after receiving notification from HHS that the leave records have been changed to show LWOP for the period. The employee will then only have to refund to HHS the difference between (1) gross value of the salary or wages paid to the employee while in leave status, and (2) the amount of compensation paid directly to HHS by OWCP. Because leave is paid at 100% of the usual wage rate and compensation is paid as a percentage, the employee will generally owe HHS money for the leave repurchase.
- An employee who uses leave and requests to buy it back, may file a claim for compensation on Form CA-7 while still in leave status. In the interim, OWCP will consider and resolve any points at issue. No compensation payments are issued, however, while the employee is still in leave status. The OWCP will issue instructions to the employee after receiving the CA-7 concerning "buy back requirements."
- When the employee "buys back" leave, the leave records (e.g., Form. HHS-402) must be amended and reconstructed on a pay-period basis as of the time the leave was used to reflect the change from paid leave status to LWOP and to reinstate the sick and/or annual leave. In some cases when such adjustments involve prior leave years, unless the employee is counseled correctly, he/she may unwittingly "buy back" annual leave which immediately becomes subject to forfeiture. For example, if the employee "buys back" annual leave which is reinstated to a prior leave year and the reinstatement causes a leave balance at the end of that leave year which is in excess of the maximum authorized accumulation (usually 240 hours), the excess leave will immediately be forfeited at the beginning of the leave year following the year to which it is reinstated. Therefore, where this is likely to occur, the supervisor should consult with the personnel office to ensure that an employee who contemplates the "buy back" of annual leave is told the amount of leave which can be reinstated for use and is advised not to "buy back" the annual leave that is subject to forfeiture. The supervisor and the personnel office should be contacted before advising an employee on the procedures of buying back annual leave.
Cases Involving Third Party Liability.
- Health Benefits.
The employee should be informed that the benefits provided under the Federal Employees Health Benefits Plans do not apply when treatment, care, or services are covered under the Federal Employees', Compensation Act.
- Civil Service Retirement.
As a general rule, a person may not concurrently receive compensation from OWCP and a retirement or survivor annuity from the Office of Personnel Management. The person may elect to receive the more advantageous benefits.
Hearings, Reconsideration, and Appeals..
- When it appears that a party other than the U.S. Government is involved in or liable for an employee's injury, illness, or death, the supervisor and/or other appropriate IHS official will investigate the third party aspects and submit a report of the findings with related documents to OWCP. Third party cases may include claims against individuals or product manufacturers but normally another employee is not considered a third party (instructions attached to forms CA-1 and CA-2 cite instances that could be considered a third party to an injury or occupational disease/illness).
- The employee will be contacted with specific instructions concerning this aspect of the claim. He/she should not try to settle the claim without first obtaining advice and approval from the Solicitor of Labor through OWCP. The supervisor will tell the employee about this requirement.
A formal decision is issued by OWCP any time an adverse decision involving entitlement is reached such as denial of an initial claim or denial of continuing benefits. Three avenues of appeal are provided for claimants (employees) to contest such actions (Agencies are not entitled to appeal). Claimants may request only one form of appeal at a time as follows:
- Hearing. The claimant is entitled to either an oral hearing before an OWCP representative or a review of the written record (but not both), as long as a written request is made within 30 calendar days of the formal decision, and a reconsideration has not already been requested. The request should be sent to the Branch of Hearings and Review at the address included with the appeal rights; no special form is needed.
If an oral hearing is requested, the claimant may present written evidence or oral testimony in support of the claim. The IHS will be notified when the hearing is scheduled and advised that it may request a copy of the transcript and/or send a representative to the hearing. However, the IHS representative may not participate in the proceedings unless specifically invited to do so by the claimant or OWCP representative.
If a review of the written record is requested, the claimant may not present oral testimony, but may submit written evidence or argument. IHS will be given 15 calendar days to submit comments and/or additional documents, which will be subject to review and comment by the claimant within an additional 15 days.
After the hearing is held or the review of the written record is completed, OWCP will issue a formal decision, including a description of the claimant's further appeal rights.
- Reconsideration. A claimant may ask OWCP to reconsider a formal decision made by the district office. The request should be addressed to the district office handling the claim; no special form is required, but the request should clearly state the ground on which it is based. It must also be accompanied by relevant evidence not previously submitted or arguments for error in fact or law in reaching the contested decision. A reconsideration must be requested within 1 year of the date the contested formal decision was issued.
For any request which meets the above criteria, OWCP will provide IHS with a copy of claimant's request, and allow 15 calendar days for submission of comments and/or documents, which will in turn be subject to claimant review and comment within 15 days. Following OWCP reconsideration, a new formal decision, which includes a description of the claimant's further appeal rights, will be issued.
- A claimant may request review by the Employees' Compensation Appeals Board (ECAB), which is the highest authority in Federal workers' compensation claims. The claimant should file for such review directly with the ECAB at the address included with the formal decision. The ECAB's review is based solely on the case record at the time of the formal decision; new evidence is not considered. Normally, a claimant has 90 calendar days from the OWCP final decision to file an appeal with ECAB.>
1-8.7 COST CONTROL
- A regular process at the Headquarters level will be to allocate to each Area office that Area's share of FECA costs as reported to the IHS by HHS.
- Each Area must carefully review both annual OWCP billings (final billings are from the fiscal year of 2 years earlier) and periodic quarterly OWCP billings (furnished quarterly on the current year cases that are currently being paid by OWCP) to ascertain whether each FECA case listed is actually that Area's responsibility or whether it should be reassigned to another IHS Area or to a different Federal department or agency altogether.
- A case clearly charged to the wrong HHS Agency or IHS Area must be correctly recoded and the correction reported to the Chief, Personnel Management Assistance Branch (PMAB), Division of Personnel Management, Office of Human Resources, Rockville, Maryland, for correction to the permanent OWCP file. The Chief, PMAB, is responsible for any corrections at the Department level for internal HHS allocation and reassignment of cases to the proper HHS agency component.
- For each case that does not match any Area employment or previous Area FECA file, the Area SPO must arrange for an on-site investigation at the appropriate OWCP district office to determine, from the contents of the OWCP case file, whether the case is an IHS responsibility and, if so, which IHS Area, other HHS agency, or a different Federal department should be identified as currently responsible. Where such investigation reveals that the case should be reassigned, corrective recoding should be reported as specified in section l-8.7B above.
It is the exclusive role and responsibility of the DOL/OWCP to adjudicate claims. The OWCP regulations require that any person charged with the responsibility for making reports in connection with an injury who willfully fails, neglects, or refuses to do so; induces, compels, or directs an injured employee to forego filing a claim; or willfully retains any notice, report, or paper required in connection with an injury, is subject to a fine of not more than $500 or imprisonment for not more than 1 year, or both.
In regard to the employee or person acting on his/her behalf, the penalty provision on the compensation form requires the following:
- Any person who knowingly makes or knowingly certifies to any false statement(s), misrepresentation, concealment of fact, or any other act of fraud with respect to a claim, and who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate provisions, be punished by a fine of not more than $10,000, or imprisonment, or both, or
- Any person who with respect to the claim enters into any agreement, combination, or conspiracy to defraud the United States by obtaining or aiding to obtain the payment or allowance of any false, fictitious, or fraudulent claim is subject to criminal prosecution and may be punished by a fine of not more than $10,000 or imprisonment of not more than ten years, or both.
- 5 U.S.C. 8101, et. seq.
- 20 CFR 10.1 through 10.624.
- HHS Instruction, Chapter 810-1, Management of the Injury Compensation Program.
- Indian Health Manual, Chapter 9, Occupational Safety and Health Program.
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